Basic instrumentation in endoscopy

Laparoscopic surgery or minimally invasive surgery (MIS) has numerous advantages such as less pain , less blood loss, early recovery and shorter hospital stay.

1. BASIC INSTRUMENTs of ENDOSCOPY & Its Limits

2. Dr. Niranjan Chavan MD, FCPS, DGO, DFP, MICOG, DICOG, FICOG Professor and Unit Chief, L.T.M.M.C & L.T.M.G.H Chairperson, FOGSI Oncology and TT Committee (2012-2014) Treasurer, MOGS (2017- 2018) Chair and Convener, FOGSI Cell- Violence against Doctors (2015-2016) Chief Editor, AFG Times (2015-2017) Editorial Board, European Journal of Gynecologic Oncology Editor of FOGSI FOCUS, MOGS, AFG & IAGE Newsletters Member, Managing Committee, IAGE (2013-2017) Member , Oncology Committee, AOFOG (2013 -2015) Recipient of 6 National & International Awards Author of 15 Research Papers and 19 Scientific Chapters Course Co-Ordinator, of 11 batches, of MUHS recognized Certificate Course of Basic Infertility Management Including Endoscopy (BIMIE) at LTMGH

3. VERESS NEEDLE Available both in disposable and reusable form Used for creating initial pneumoperitoneum Has two component : an outer hollow needle with sharp bevelled edge and a blunt, spring loaded inner obturator with the stop position beyond tip of the hollow needle. Available in 3 lengths : 80mm, 100mm and 120 mm

4. VERESS NEEDLE Umbilical area is preferred for inserting veress needle, as subcutaneous area is reduced here. A transverse incision is taken before inserting the veress needle. It is advisable to lift the abdomen to move the large vessels away. Needle passes through the wall and fascia, there is ‘Popping’ sensation

5. VERESS NEEDLE Safety tests for veress needle : Irrigation and aspiration test Hanging drop test Gas insufflation test Alternative site for veress needle insertion are : left upper quadrant, left iliac fossa and the posterior pouch of Douglas

6. Limitations of Veress Needle It can go in the abdominal wall Subcutaneous emphysema can go up to the neck if not detected early Can cause injury if the angulation of the entry point is misdirected leading to injury to internal organs viz. Bladder if not emptied , Uterus Bowel perforation, if appropriate bowel preparation is not done. Vessel injury like aorta, mesenteric vessels

7. TROCAR 1 . Trocar with pyramidal tip 2 . Trocar with conical tip 3 . Trocar with blunt tip Trocar permit access to peritoneal cavity. It can be inserted primarily or after creating a pneumoperitoneum of 15mmHg through veress needle. Trocars are available in various design : with pyramidal tip, conical tip or blunt tip.

8. TROCAR Ideal way to hold a trocar : proximal end resting on T henar prominence, with thumb on one side and rest of the four fingers on the other side with middle finger on gas inlet and index finger pointing towards the sharp end. Axis of insertion : cranio – caudal direction Angle of inclination : 45 degrees to perpendicular axis and slight trendlenberg position of the patient.

9. TROCAR An alternative method is Visually Controlled Entry . It involves use of a reusable 11mm cannula with a 0 degree endoscope, which provides direct visualisation of the entry tract. Ternamian EndoTIP , Visiport , Optiview

10. Limitations of TROCAR False passage Subcutaneous emphysema Injury to internal organs wiz Bladder if not emptied , Bowel , Uterus , Ovary etc. Vessel Injury viz Aorta, Mesenteric Vessels.

11. ELECTRONIC CO2 ENDOFLATOR It is an insufflation unit for delivering CO2 to the peritoneal cavity for laparoscopy surgery. Maximum capacity to insufflate up to 15 – 20/min and to maintain an intra – abdominal pressure of 12 -16 mmHg.

12. ELECTRONIC CO2 ENDOFLATOR Important Insufflation parameters are: Pre-set Insufflation Pressure : should be approximately 12 – 14 mmHg 2. Actual Intra – abdominal Pressure : should never exceed 25mm Hg as it would lead to compression of IVC 3. Gas Flow Rate : initially it should be 1 – 2L/min 4. Total Volume of Gas Inflow : in normal size human , 4 – 5L of CO2 is required for intra – abdominal pressure of 12 mmHg

13. Limitations of Insufflator Insufflator shows the intra abdominal pressure , 4mmHg more than the actual pressure If Intra abdominal pressure rises > 25 mmHg, there is risk of: 1. Compression of IVC 2. Deep vein thrombosis 3. Air embolism 4. Surgical Emphysema

14. ENDOSCOPEs It is state of art instrument which produces images of the concealed body cavity. The rod lens system used in Endoscope was introduced by professor Harold H Hopkins ( his photo) . Kurt Semm , father of modern gynaecologic endoscopy, popularised used of endoscopes for diagnostic purposes, invented the insufflator , uterine manipulator amongst other things. Harold H Hopkins Kurt Semm

15. ENDOSCOPEs Endoscopes are available in various diameters, length and angles Diameters available : 1.5 mm for micro laparoscopy, 5mm for diagnostic laparoscopy, 10mm for operative laparoscopy. Angles available: 0 (used in gynaecology), 30 , 45 Flexible fiberscope provides allow the angle of vision to be adjusted by active deflection of the distal tip. They are used in digestive tract or tumour surgery.

16. VIDEOENDOSCOPY Single chip video camera Three chip video camera In modern laparoscopy, a good video camera is a must. The technical criteria of a good camera is high resolution (pixels), sensitivity (lux), signal –to – noise ratio, number and quality of video output ports. Most important component is CCD sensor, a solid state chip embedded with a series of a tiny, light sensitive photosites capable of producing various amount of charge on incidence of light.

17. VIDEOENDOSCOPY In 2002, 1 st generation of digital camera was introduced in name of IMAGE1, which had digital source sampling (DSS) technique. Camera should be focussed before inserting, by focussing on a target area 5cm away from camera and set the white balance It is done by focussing on a white object. Fully equipped video cart

18. VIDEOENDOSCOPY IMAGE H3-Z, 3 chip high definition camera : uses 1080p (p stands for progressive scan). It is the highest resolution for distribution and broadcasting of video content. Advantage : Digital still images, video and audio files can be used for consultation, review , medicolegal purposes and promotes ‘Telemedicine’. AIDA : Advanced Image and Data Archiving system provides an excellent tool for data storage

19. VIDEO MONITOR Flat screen high-definition (HD), Video monitor WIDEVIEW HD Surgical monitors based on the principle of Electronic Horizontal Linear Scanning. There are 3 main analogue television broadcasting system: PAL, SECAM and NTSC. NTSC has 525 lines of resolution, PAL and SECAM works on 625 lines The final image depends upon no. of lines of resolution, pixels and scanning lines.

20. VIDEO MONITOR Optical vision is of paramount importance for the outcome of any surgery World’s largest 23 inch LCD video monitor with 16:9 frames , improves anatomical orientation rather than conventional 4:3 frames Other Advantages include better Visualisation of lateral aspects, Higher depth perception and better Contrast , resulting in better Differentiation of Anatomical Planes Comparison of 16:9 and 4:3 frames

21. LIGHT SOURCE AND CABLE Light source and cable is very important as adequate illumination is necessary for video laparoscopy and minimal invasive surgery. Light source is most important part of electro- optical system. Light source mainly depends on the lamp. 2 types are available :- Halogen and Xenon

22. LIGHT SOURCE AND CABLE Cold light source XENON 300

23. LIGHT SOURCE AND CABLE Light source’s luminous efficacy is quotient of the total luminous flux emitted divided by total lamp power input 175 - 250 watt generally sufficient for routine endoscopic procedure For miniature endoscopes, 300 watts of light source is required as minimal bleeding obscures the view

24. TELE PACK x It is a compact unit consisting of light source, Camera Control Unit, Monitor and documentation Module. Other features include 15" LED backlight display Image rotation 24 bit colour depth for natural colour rendition DVI-D video output for connecting external monitors High-performance LED light source similar to Power LED 175

25. LIGHT SOURCE AND CABLE 2 type: Fibre optic and Liquid - crystal gel cable Medical grade fibre optic cable consists of Fibre Glass Bundles, surrounded by a cladding layer which allows propagation of light by total internal reflection. Diameter ranges from 3.5 mm – 6 mm Length ranges from 180cm – 300cm For general laparoscopy , a light cable of 5 mm diameter and 240cm length is used

26. LIGHT SOURCE AND CABLE Fibre optic light cable Fibre Optic Cable Liquid Crystal gel cable Core has fibre optic bundles Has sheath filled with clear gel like fluid Fragile , glass optic fibre may crack Extremely fragile, due to quartz at the ends More flexible and transmits less heat Transmits 30% more light

27. Limitations of Imaging SYSTEM Endoscopes only provide a visual feedback and lacks tactile feedback, resulting in deficiencies in eye – hand coordination. The traditional 4:3 video monitors lack proper depth perception and anatomical orientation, as it creates only 2 dimensional image of body cavity. The cold light source emits harmful UV radiation A major drawback of light cables is the relative fragility.

28. FORCEPS AND SCISSORS Connector pin for unipolar coagulation Insulated metal outer sheath Forceps insert Handle A set ergonomics instrument is perquisite of successful of laparoscopic surgery. Most hand instruments can be divided into : handle, insulated metal sheath and working insert. Working insert may be a F orceps, G rasper and S cissor.

29. FORCEPS AND SCISSORS Various single action grasping forceps Various double action grasping forceps Heat insulation can be made of nylon or heat shrinkable plastic Hand instruments can be reusable or disposable Diameter ranges from 3mm to 10mm Grasping forceps can be single action (used in adhesiolysis) or double action

30. FORCEPS AND SCISSORS Straight scissors Curved scissors Scissors with serrated blade Hook scissors Straight scissors : used for mechanical dissection and for cutting sutures. Curved scissors : most commonly used scissors in laparoscopy due its ergonomic advantage. Scissors with serrated blade : used for cutting slippery tissue. Hook scissors : useful for transection of ducts, arteries or ligaments.

31. Needle Holder & SUTURing TECHNIQUES Advanced laparoscopic procedures can be performed safely only with surgeon’s suturing and knot tying technique. There are Two suturing methods: Intra-Corporeal and Extra-Corporeal technique Another method is laparoscopic clip. Most of them are made of pure titanium or of titanium alloys.

32. SUTURE TECHNIQUES Macro needle holder with ergonomic handle Various needle holder with curved jaws The major steps of the intracorporeal technique are: 1. introduction of the needle 2. intraabdominal suturing 3. placement of suture ligatures 4. knot tying

33. SUTURE TECHNIQUES Knot tier for extracorporeal knotting As the term denotes, extracorporeal suturing and knot tying is performed outside the body cavity. Once the tissue is sutured, the needle is removed through the trocar cannula and the suture is completed extra corporeally. For e.g. Roeder knot in hysterectomy In this case, a knot tier is required.

34. UNIPOLAR ELECTRoSURGERY Unipolar needle electrode In Unipolar Electro surgery, the active electrode is at surgical site. The patient return electrode (grounding pad) is elsewhere on the body. It may be used for coagulation, pure section and coagulation – section by use of mixed current. Coagulation current is intermittent current. Cutting current is continuous current.

35. UNIPOLAR ELECTRoSURGERY Various shape of Unipolar electrode are available according to use Spatula : W shaped or Blunt tipped Hook : L- , J- , U- configuration Ball shaped Barrel shaped Straight Blunt tipped is used for endometrial ablation

36. BIPOLAR ELECTROSURGERY In bipolar system, current flows from one jaw (1 st electrode) through the tissue to other (2 nd electrode). Flow of electrode is restricted to a smaller area, so chances of iatrogenic injury, current arching, capacitive coupling and direct coupling is reduced.

37. BIPOLAR ELECTROSURGERY Coagulation in bipolar system is due to steep increase of temperature in the tissues. There is risk of patient burns. Disposable and reusable, both kinds of Bipolar instruments are available in various shapes. In gynaecological surgery, bipolar forceps of 3mm width is preferred. Smaller the width of the electrode, lesser is the thermal effect. So 1.5mm width is used in micro electro surgery.

38. Limitation of instruments The surgeon has limited range of motion at the surgical site resulting in a loss of dexterity Surgeons must use tools to interact with tissue rather than manipulate it directly with their hands, causing reduced judgement Reduced tactile sensation The tool endpoints move in the opposite direction to the surgeon's hands due to the pivot point, making laparoscopic surgery a non-intuitive motor skill that is difficult to learn This is called the Fulcrum effect

39. SUCTION AND IRRIGATION Suction Irrigation system Suction cannula Suction cannula varies from 5mm (standard) to 10mm(used when haemoperitoneum > 1500ml) Uses of suction and irrigation are: Lavage of abdominal cavity Control of bleeding Aspiration of clots Aspiration of fluid content of cysts Injection of vasoconstrictive agents Hydro dissection

40. EXTRACTION BAG Disposable extraction bag It prevents Benign dissemination in endometriosis, ectopic pregnancy, and benign ovarian cysts Spillage during removal of a benign teratoma, risks of infection (pyosalpinx), Malignant dissemination (suspected cysts).

41. MORCELLETOR SYSTEM An electronic or manual morcellator can be used for piecemeal removal of large specimens, such as fibroids or the uterus during laparoscopic hysterectomy, and particularly, supracervical hysterectomy. ROTOCUT G1 morcellator : - automatic - autoclavable - maximum speed of 1200 rpm - removable blade of sizes 12 -15 mm Rotogut G1 Morcellator

42. MORCELLETOR SYSTEM The removal of large portions of tissue may also be accomplished with the aid of endoscopic cold knives introduced through a minimal abdominal incision or vaginal puncture. During laparoscopic myomectomy, it is essential to have a screw- or spiral-tipped instrument that allows for proper fixation and removal of subserous or intra-mural fibroids. Myoma fixation instrument with screw-shaped tip